Mental health professionals are not supposed to lose a friend or family member to suicide. We are supposed to know the signs, respond appropriately, and prevent it. Despite the fact that about 20% of therapists will lose a client to suicide during their life of practice, we rarely talk about it. However, I have to report the sad news that I did just that. Literally a month after I completed the Mental Health First Aide certification and within a year of presenting a professional workshop on suicide prevention, my good friend died by suicide. She had been my friend for 35 years.

I can truly say she was the most loving and optimistic person I knew. She was married and had an adult daughter whom she loved deeply. Her marriage, although it had the usual bumps, was well on its way to a second wind. She was a person whom I often put forth as a role model of how to manage the illness of depression in a successful manner. She ate healthy food, exercised regularly, completed a course on mindfulness, and took her medication. She never had an incidence of self-harm. She had no previous suicide attempts and had never said a word that would indicate that she was thinking of suicide or death.

So when I first responded to this news, I went through all the normal reactions: shock, sadness, and anger. I talked about not suspecting a thing. I talked about seeing her two weeks before her death and thinking everything was great. She had plans for the future and she had things she was looking forward to. She had none of the signs (previous attempts, history of self-harm, lack of future thinking, comments about death or suicide) that we, as mental health professionals, are told to look for.

But I couldn’t let it go. The same thoughts woke me up in the morning and I wrestled with them before bed each night. What had I missed? What could I have done differently? Finally, I had to face the truth. There had been signs of trouble. I did not see them as threats. Sometimes I felt irritated by them. Other times, I felt slightly embarrassed for her. I know this is codependent but I am being completely honest here. I did not call it out directly or sneakily worm those concerns into our conversations. As much as I want to deny it, me - a mental health professional, was shamed into denial of mental health problems.

What did I see? Well for one thing, she had crying spells without cause. She was hanging into specific regrets over long past events that did not happen the way she believed they did. She shared feelings indicating a sense of being disconnected. She was worried about being forgetful. She was not sleeping well. Yet, I was silent. I did not point out my observations to her or her family. I did not suggest action or take any action myself. I keep reviewing the steps she must have taken as she made her plan to die. I continue to deny that this could really have been her desire. She would never have wanted to hurt me, her family, or her friends. I have struggled daily to understand. The only way I can put her suicide together with the person she was, is to think of her behaviors that day as a brain attack.

I know I am not responsible for her death; I am not that codependent. However, was it possible to have intervened in some way? Was I as good of a friend to her as she was to me? It is certainly true that if I had intervened, she could have died by suicide anyway, or possibly sooner. The road to anxiety is paved with possibilities. And obviously, there is no going back. But mostly, I just want to scream at myself and the world: the brain is just another organ that gets sick. It gets sick like a kidney or a lung. Sadly we, as a society, have no way of managing that.

Going forward, I have made these promises to myself. I will always talk openly about mental health regardless of how uncomfortable it is. I have made it clear to my friends and family that I want complete honesty if they have questions about my mental health or cognitive function. I will speak up if I see changes in cognition among friends and family. I will ask the hard questions whenever I see any potential for suicide, including indications cited in the interpersonal theory of suicide. I will renew my faith in the power of connection with others to bridge these gaps in comfort. I will learn to get more comfortable with the fact that all of our organs can suffer from imperfection, change, and age.

Libby Bergman, LICSW, was one of three co-founders of the Family Enhancement Center and has served as the Executive Director since 2000. Libby has worked with youth and families for over 25 years. Libby was the recipient of the 2011 Children’s Law Center of Minnesota’s Heroes for Children Award. She was honored again in 2013 with the University of Minnesota School of Social Work Alumna of the Year.

This is the third in a series of five articles about lessons that I have learned in the school of experience and hard knocks, rather than in graduate school. The first dealt with the ethical considerations when you leave a practice. The second focused on the necessity of proper documentation and the potential consequences of not properly documenting mental health services. This article describes the importance of writing treatment plans in which clients’ progress can be measured and evaluated in clear, not vague, terms.

My training: In graduate school I was taught that treatment plans were a description of the intended services to be provided to a client (i.e., the plan for treatment). The information was to include the diagnosis, the type of therapy (e.g. individual or group), the mode of therapy (or school of thought), the number of expected sessions, a list of problem areas to be addressed in the counseling, the goals and objectives for client change, plus a list of client’s strengths and areas of concern. We were taught to have at least three goals and at least three objectives for each goal.

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